The Medicaid Rate Setting and Audit Section manages annual reimbursements made under various long-term care reimbursement methodologies, including methodologies for specialized services, for Medicaid recipients receiving long-term care services in nursing facilities and adult day health care facilities. The annual expenditures of such expansive sums under a capped amount of federal fund participation with open-ended recipient rights to services necessitates constant interim monitoring projections, analyses and meetings with federal, state and contracted auditors. Technical, comprehensive and detailed analyses are prepared and constantly updated to ensure maximum program effectiveness and accountability. Louisiana Medicaid Rate Setting and Audit Section contracts with CPA consultant firms for the development of rate methodologies and for the audit of Medicaid providers participating in the long-term care programs. This section monitors these contracts, reviews, and approves the consultants’ audits, desk reviews, and audit programs and then authorizes payments.

To speak to someone from this office, call Medicaid Rate Setting and Audit Section at 225.342.6116. Please click here to see contact information for Medicaid Rate & Audit staff.

Adult Day Health Care

Effective July 1, 2011, a new reimbursement methodology was implemented for payment to Adult Day Health Care (ADHC) providers. ADHC providers will be reimbursed at a quarter hour (15-minute) rate of pay instead of a "per diem" or daily rate. ADHC facilities provide direct care to individuals who are physically and/or mentally impaired. ADHCs target those individuals who need direct professional medical supervision or personal care supervision. Eligibility requires that individuals would require intermediate care or skilled nursing services.

Information on adult day health care forms and resources are available from Louisiana Medicaid Rate Setting and Audit Section. If additional information is needed, please call 225.342.6116.

Submission of ADHC Cost ReportsThe ADHC annual cost reports (facility and central office) covering the period of July 1st through June 30th must be submitted by September 30th. The ADHC cost report software is available free of charge at http://la.mslc.com/Downloads.aspx. Providers must use this software for all cost reports. If a provider experiences unavoidable difficulties in preparing its cost report by the prescribed due date, an extension may be requested. If cost reports and all accompanying forms are not received by Myers & Stauffer, LC by Sept. 30 (or an extension date is granted) penalties may be assessed. If the calculation of Direct Care Cost Settlement shows money due to LDH, do not remit payment with the cost report. The provider will be notified of the amount due after desk review or audit.

Nursing Home Case Mix Reimbursement Methodology

This reimbursement methodology is based on using the Medicare Minimum Data Set to determine the level of needs of Medicaid recipients in nursing facilities and to ensure that nursing facilities receive a level of reimbursement commensurate with the level of services needed for each resident. It requires that nursing facilities expend a set amount of funding received for the provision of direct care services. If expenditures for direct care are not at an acceptable level, the nursing facility must reimburse the department for a portion of the funding received. This methodology assures reasonable access to care for persons needing high levels of nursing facility care.

The Louisiana Department of Health (LDH) has a contract with a professional CPA firm to perform on-site audits of Medicaid cost reports submitted by nursing facilities, intermediate care facilities for the mentally retarded (ICF/MR), and adult day health care (ADHC) facilities. In addition to the audit function, the contractor performs desk reviews of Medicaid cost reports for private nursing facilities, ICF/MR, and adult day health care facilities. The contractor calculates rates for the private ICF/MR, adult day health care facilities, and nursing facility specialized services [Skilled Nursing – Infectious Disease (SN/ID), Skilled Nursing – Technology Dependent Care (SN/TDC) and Neurological Rehabilitation Treatment Programs (NRTP)]. These functions are performed to determine that providers are reimbursed within the Department’s regulations and according to the Medicare Provider Reimbursement Manual (HIM-15) principles. The LDH Rate and Audit Review Section maintains all of the audit information compiled by the contractor. This section follows up on audit issues, as necessary.

Minimum Data Set (MDS) Medical Records Review Overview

A periodic case mix medical records review is completed for all Louisiana licensed nursing home facilities as appropriate under state rule.The case mix medical record review is conducted for the following assessment selection:

A minimum of 20% of the occupied census or 10 medical records, whichever is greater, and

A random sample of those residents in each of the Resource Utilization Groups (RUG-III) where possible

Medicaid Administrative Claiming (MAC)LDH recognizes that schools offer a unique advantage and opportunity to outreach potential and current Medicaid recipients to help them access Medicaid covered services. The purpose of the Medicaid Administrative Claiming program is to assist eligible and potentially eligible Medicaid individuals in accessing services covered by the Medicaid program by using activities such as outreach, referral, case coordination, and follow-up.

Durable Medical Equipment

Durable medical equipment (DME) and supplies must be provided by State Medicaid agencies as part of the Home Health Services benefit. Home Health services must be provided in a recipient’s place of residence, and a recipient’s place of residence cannot be a nursing home, hospital, or Intermediate Care Facility for the Mentally Retarded (ICFMR). CMS advised that it is the responsibility of the facility to provide DME and supplies to its residents, and the state must make payment for these items to the facility.

Prosthetic devices are defined as “replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by state law to:

(1) artificially replace a missing portion of the body;

(2) prevent or correct physical deformity or malfunction; or

(3) support a weak or deformed portion of the body.”

Therefore, prosthetic devices are not provided as part a Home Health service and may continue to be provided by prosthetic suppliers, when medically necessary and authorization has been given by the Prior Authorization Unit at Unisys. Prosthetics include artificial eyes, limbs, support braces, corrective shoes and braces, cochlear implants, shoe inserts, breast prostheses, hearing aids for recipients under the age of twenty-one (21) years of age, surgical stockings and other similar items.